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CPAP Workshop

CPAP Workshop. Dr. Gautam Ghosh Dr. Chandan Roy Dr. Ashok Modi Dr. Debjani Gupta Dr. Amit Roy. Definition.

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CPAP Workshop

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  1. CPAP Workshop Dr. Gautam Ghosh Dr. Chandan Roy Dr. Ashok Modi Dr. Debjani Gupta Dr. Amit Roy Dr. Gautam Ghosh

  2. Definition • CPAP : It is a modality of respiratory support in which increased pulmonary pressure is provided artificially during the expiratory phase of the respiration in a spontaneously breathing neonate. • IPPV or IMV : Breathing is taken over completely by the machine & increased pulmonary pressure occurs during both inspiration & expiration. Dr. Gautam Ghosh

  3. Historical review • Poulton & Oxam 1936 • Gregory et. Al 1971: first trial • Agostino et.al 1973 : first RDS managed with CPAP. • Bubble & Dual flow CPAP (Infant flow drive) Dr. Gautam Ghosh

  4. Types of CPAP • Oxygen hood • Bubble CPAP & Dual flow • CPAP machine • Ventilator Dr. Gautam Ghosh

  5. Physiological effects Dr. Gautam Ghosh

  6. Various Modes of CPAP Dr. Gautam Ghosh

  7. Newer CPAP • Bubble CPAP : vibration (high frequency?) / may be less CLD (?) • Dual flow : Infant flow driver / fluidic flip mechanism / more stable PEEP control / failed nasal CPAP – try Dual flow CPAP—failed –try IMV Dr. Gautam Ghosh

  8. Effect on Blood gases • Oxygen : Improves due to increase in FRC through recruitment of atelectatic alveoli. • CO2 : Decreases due to availability of greater surface area for gas exchange due to recruitment of alveoli. Excessive CPAP(> 7 cm) leads to over-distension of alveoli and CO2 retention. • CPAP improves p O2, p CO2 change is secondary. Dr. Gautam Ghosh

  9. CPAP Ranges Fi O2 controlled from 0.2 to 1.0 with CPAP. Dr. Gautam Ghosh

  10. Indications of CPAP • Respiratory distress, moderate /severe: retraction or grunt. • Recurrent apnea • P aO2 < 60 with FiO2 > 0.6 ( O2 hood). • Early : within 2 hrs of distress. • Late ; after FiO2 requirement > 0.6 Dr. Gautam Ghosh

  11. Guidelines for CPAP • Start with nasal CPAP of 5—6 cm & FiO2 0.4—0.5 • Increase CPAP by 1 cm if required • Reach a CPAP of 8—9 cm. • Now increase FiO2 in small steps of 0.05 up to 0.8 • Clinical /ABG / SpO2 > 30min in each step • Do not raise FiO2 before pressure : may remove hypoxic stimulus -- apnea • Revert to IMV if not responding Dr. Gautam Ghosh

  12. Weaning from CPAP • Reduce nasal CPAP TO 8 cm • Reduce FiO2 by 0.05 to 0.4 • Reduce CPAP by 1 cm decrements • Reach a level of CPAP 4cm / FiO2 0.4 • Remove CPAP and replace a O2 hood. Dr. Gautam Ghosh

  13. Optimum CPAP • Comfortable baby / pink / normal BP • No retraction / grunt • No cyanosis / normal CRT • CRT < 3 SEC • SpO2 > 90-93 % • ABG : PaO2 60-80 / PaCO2 40-45 /p H 7.30-7.40. • Diagnosis ; Xray Chest in supine : Post. Intercostal space 7-8 (if > 8 : reduce PEEP / IF < 5 : raise PEEP) Dr. Gautam Ghosh

  14. Failure of CPAP • Retraction / Grunt ++ • Apnea on CPAP • PaO2 < 50 in FiO2 > 0.8 ( nasal CPAP >8cm) • PaCO2 > 55 • Baby not tolerating CPAP. • Commonest cause : delay in starting Dr. Gautam Ghosh

  15. Monitoring CPAP • Clinical : comfort /RR,grunt,retraction /Cyanosis/HR, pulse / CRT,BP / Temp ./ Abd.girth / Urine / CPAP machine • Pulse Oximetry ; set alarm at 88%(L) & 95%(H). • ABG : wait for 15-30 min after each setting. Dr. Gautam Ghosh

  16. Practical Points in CPAP • Warm gases at 34—37* C & humidify. • Gas flow (21/2 times minute ventilation) at 5-8 L/M minimum • Look for nasal or oral blocks by secretion • Oro-gastric suction is a must • Stabilize the head with a cap and string • Change CPAP circuit/prong every 3 days • Asepsis. • Sedation ?? • Feed : oro-gastric 10 ml/kg EBM Dr. Gautam Ghosh

  17. CPAP & RDS • Prevent atelectasis/ preserve surfactant / avoid IMV • Early better than late / no role in prophylactic CPAP • INSURE : intubate / surfactant /extubate / CPAP with early signs( a/A o2 <0.36) • Surfactant by CPAP ; future ?? Dr. Gautam Ghosh

  18. CPAP & Other disease • CPAP after extubaion : Nasal better than ET tube CPAP / SNIPP (synchronised nasal intermittent positive pressure ventilation) • MAS : better in atelectatic than over-inflated lung Dr. Gautam Ghosh

  19. Complications of CPAP • PAL : tends to occur when O2requirements are decreasing & compliance improving • Excess PEEP : V /Q mismatch due to excess flow in under-ventilated lungs. Dr. Gautam Ghosh

  20. Future • With chance of cost of surfactant coming down in future, CPAP may be a better alternative in RDS. • Noninvasive ventilation Dr. Gautam Ghosh

  21. Case 1 • 30wks, Uncontrolled APH, 30 yrs , 4th gravida, P 1+2, LUCS, 1 dose Dexa 12 hr before birth • BVm with 100% O2for resuscitation, APGAR 5/1, 8/5. 1280 gms female • Cord blood PCV 56%, Sepsis screen –ve, gastric aspirate shake test –ve. • 1hr: tachypnea, retractions, Spo2 82% • Put on O2 hood (Fio2 0.5) Dr. Gautam Ghosh

  22. ABG tree Dr. Gautam Ghosh

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